The State of Transgender Health Care

Policy, Law, and Medical Frameworks

Daphna Stroumsa, MD, MPH

Disclosures

Am J Public Health. 2014;104(3):e31-e38. 

In This Article

Abstract and Introduction

Abstract

I review the current status of transgender people's access to health care in the United States and analyze federal policies regarding health care services for transgender people and the limitations thereof. I suggest a preliminary outline to enhance health care services and recommend the formulation of explicit federal policies regarding the provision of health care services to transgender people in accordance with recently issued medical care guidelines, allocation of research funding, education of health care workers, and implementation of existing nondiscrimination policies. Current policies denying medical coverage for sex reassignment surgery contradict standards of medical care and must be amended.

Introduction

The term transgender is an adjective that has been widely adopted to describe people whose gender identity, gender expression, or behavior does not conform to what is socioculturally accepted as, and typically associated with, the legal and medical sex to which they were assigned at birth.[1] Gender nonconformity, or a desire to express gender in ways that differ from gender-cultural norms linked to sex assigned at birth, was until very recently considered a mental pathology by the psychiatric community.[2] Although recognition and classification of gender nonconformity appeared in Western medicine in the 1920s, gender identity disorder (GID) first appeared as a distinct diagnosis in the American Psychiatric Association's (APA's) third edition of the Diagnosticand Statistical Manual of Mental Disorders (DSM) in 1980[2] and remained a category until the newest edition of the DSM (the DSM-5).[3] Over the past few decades, after professional as well as public debates, the APA has moved toward differentiating gender nonconformity from mental illness. On December 1, 2012, the board of the APA approved changing the diagnosis of GID to that of gender dysphoria in the DSM-5,[3] a significant move toward depathologizing gender variance. Psychiatrists increasingly agree that being transgender is not an illness to be cured or overcome (nor, for that matter, a state that can be altered). However, those who suffer because of the misalignment of their physical characteristics with their gender identity may benefit from treatment.[4]

Current estimates have suggested that 0.3% of US adults, or close to 1 million people, identify as transgender.[5] (Other estimates have varied widely from a high prevalence of 1:500 or more[6] to 1:11 900–1:45 000 for male-to-female individuals and 1:30 400– 1:200 000 for female-to-male individuals.[7–10]) Demographic studies to date have been limited[7] because national surveys have not included questions recognizing gender identity. Furthermore, important methodological debates remain unresolved, including those about conflation of terms (e.g., differentiation among gender, gender identity, and sex) and appropriate ways to accurately describe the transgender population (e.g., according to self-identification, gender expression, gender identity, or wish for medical treatment).[8] One way of estimating the proportion of transgender people in the population is through data on medical care, specifically medical assistance in the process of adapting gender presentation to align with identity, a process known as transitioning. However, this approach does not identify transgender people who have not opted for or who have faced insurmountable obstacles in accessing such care. Even using the conservative estimate of 0.3%, the number of people living in the United States who identify as transgender is nearly 1 million. Health care for this population has historically been, and continues to be, overlooked by governmental, health care, and academic establishments.

Transgender people have a unique set of mental and physical health needs. These needs are compounded by prejudices against transgender people within both the medical system and society at large. These prejudices create barriers to accessing timely, culturally competent, medically appropriate, and respectful care.[9,11,12] These societal and medical barriers are associated with increased risk of violence, suicide, and sexually transmitted infections.[11] Additionally, transgender people may have health needs related to gender transition, including hormonal therapy and surgery, that can create an undesired and unavoidable dependency on the medical system for basic identity expression. This combination of high medical needs and barriers to accessing appropriate care may give rise to a selfperpetuating cycle of risk exposure, stigmatization, prejudice, and eventually poor health outcomes.

Transition-related medical care, otherwise referred to as gender-confirming therapy, is designed to assist an individual with the adjustment of primary and secondary sexual characteristics to align with gender identity.[9,13] Such therapy may include hormonal therapy, surgical therapy, or both depending on individual needs and wishes, as well as ability to access such services. Procedures for gender confirmation may include breast or chest surgery, hysterectomy, genital reconstruction, facial hair removal, and plastic reconstruction, as appropriate to the particular person.[14]

Denial of, or severely limited access to, medical care for transgender people, whether explicitly by refusal of coverage or implicitly by prejudice and lack of knowledge among health care workers, may have detrimental effects on both short- and longer term health and well-being of transgender people. Moreover, the failure to comprehensively address the medical needs of transgender people stands in contradiction to the medical profession's prized values of equity and respect.[15] As such, I argue that a new approach is urgently needed: one that not only recognizes the unique health care needs of this group of people, but does so in an ethical, principled, and timely manner.

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